Source: Annual Congress 2008 - Progress and a new era for noninvasive mechanical ventilation
Disease area: Respiratory critical care

Abstract

Introduction: Noninvasive ventilation (NIV) has been demonstrated to facilitate extubation for patients with airways diseases, however studies report very few patients with ventilatory impairment due to neuromuscular disorders (NMDs) Conventional weaning protocols for NMDs have significant risk of extubation failure, and these patients are considered unweanable.
The aim of this study was to report extubation success rates in ventilator dependent NMDs using a paradigm that included full, continuous NIV and mechanical assisted cough (MAC).
Patients and Methods:142 patients (43 females) with NMDs were submitted to a extubation protocol that included continuous NIV at full ventilatory support and MAC. Vital capacity (VC) and both unassisted and assisted Cough Peak Flows (CPF) were measured immediatelly after extubation. Extubation failure and success rates were determined as a function of assisted CPF greater than or equal to vs. less than 160 L/m, of pre- experience with NIV, of diagnosis, and by VC.
Results: All patients were cooperative with the protocol. Before intubation, 63% had no pre-experience with NIV, 25% were on nightime NIV and 12% were on continuous NIV. Mean VC and CPF at extubation were 346±177ml and 184±79 L/min respectively. Patients were intubated for a mean of 6 ± 10 days vs 2±1,5 days on our protocol. Extubation success rates were 97% (139 patients) vs 2%failure (3 patients failed extubation by having severe bulbar impairment). 16% of extubated patients were discharged with no NIV, 40% with nightime NIV and 44% with continuous NIV.
Conclusion: This protocol permits that NMDs who are considered unweanable can be successfully extubated without resort to tracheotomy.

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Citations should be made in the following way:
M. Goncalves, J. R. Bach, I. Hamdani, J. C. Winck (Porto, Portugal; Newark, NJ, United States Of America). Extubation and noninvasive ventilatory management of unweanable patients with neuromuscular weakness. Eur Respir J 2008; 32: Suppl. 52, 363

Member's Comments

Emily Ballard - 07.10.2008 15:43
Resistance from ITU?
I would just like to congratulate you on a very interesting and important piece of work. I very much agree with what you suggest as a means to facilitate extubation in unweanable NMD patients. This is a technique which I have used personally and found to be very effective when specialist staff are available but it can be very labour intensive. Although we have 24 hour access to respiratory physiotherapy I have found non specialist staff often fail to treat to the same intensity perhaps due to a lack of experience in recognising the potential for success and the skills to persist with treatment. I therefore agree that families and carers should be encouraged to help facilitate acute treatments as this is a brilliant way to educate them in recognising the need to treat acutely (in a controlled environment) and in the patient's long term management. It is something that we practise in our specialist unit, however I wonder whether the introduction of "unqualified carers" into a general ITU would be welcomed? Did you come across any resistance? If so how was that managed? I must also comment on your fantastic frog breathing technique! I am currently perfecting mine with Barbara Webber. Best wishes Emily Ballard Specialist Neuromuscular Physiotherapist/ Transitional Care Coordinator for DMD The Lane Fox Unit, St Thomas'Hospital, London emily.ballard@gstt.nhs.uk

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